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Educational assessment of students with attention deficit disorder.

* In this article, we (1) briefly review existing literature and practices regarding the assessment and identification of children with attention deficit disorder (ADD), and (2) discuss this literature in light of issues relevant to the educational assessment and identification of ADD. Since September 1991, when the U.S. Department of Education issued a policy clarification on issues involved in educating students with ADD, local education agencies have become more aware of statutory requirements regarding assessment of children with ADD under either Section 504 of Public Law 93-112 or P. L. 94-142, the Individuals with Disabilities Education Act (IDEA) (Davila, Williams, & MacDonald, 1991). Despite this awareness, we need solid information on which to base assessment and identification practices. We hope to focus professional dialogue on the general issue of what constitutes a comprehensive assessment of ADD for educational purposes.

OVERVIEW OF COMMONLY USED INSTRUMENTS TO IDENTIFY ADD

Typical practice in research and the clinical assessment of ADD involves teacher and parent rating scales, observational techniques, and interviews. Some researchers have used laboratory tasks and psychometric measures of attention, impulse control, and hyperactivity; but these measures are used primarily to validate the behavioral constructs underlying the core features of ADD and are not typically used in clinical or school practice to identify children with ADD. We describe some instruments and procedures that are used in practice, to illustrate what is available.

DSM Symptom Checklists

Although the Diagnostic and Statistical Manuals of Mental Disorders (DSM; American Psychiatric Association [APA], 1980, 1987) have provided the most generally accepted definition of the disorder based on current research and clinical practice in the field of mental health, they have significant limitations when applied to educational assessment. For example, DSM-III-R (APA, 1987) requires 8 of 14 symptoms as the threshold for diagnosis, and the severity of ADD is evaluated subjectively (many vs. few symptoms above the threshold). The same threshold and behavioral description of each symptom is applied to all age levels and to boys as well as girls. Because of the wording of the symptoms, using this threshold is likely to overidentify younger children and underidentify girls (who typically present few symptoms but may be as impaired educationally as boys) (Barkley, 1990a).

Several rating scales are available to quantify DSM diagnosis by collecting parent and teacher ratings on the behavioral symptoms of ADD described in DSM-III and DSM-III-R. In general, these instruments use a 4-point scale from "not at all" to "very much." The SNAP rating scale (Swanson & Pelham, 1988), provides separate scores for the three behavioral constructs of ADD in DSM-III (i.e., inattention, impulsivity, and hyperactivity) and ratings of problems with peers (fights, bossiness, is disliked). Similarly, the ADHD Rating Scale (DuPaul, 1991) gathers teacher and parent ratings on the 14 symptoms of ADD as specified in DSM-III-R. Both the SNAP and ADHD Rating Scale can be scored to assess ADD with and without hyperactivity, both can assess the number of symptoms that meet the threshold for DSM diagnosis, and both have norms for quantitatively assessing severity.

Other Measures of Primary Characteristics

Several instruments have been developed that are not specific to DSM criteria, but measure the primary features of ADD. The ADD-H Comprehensive Teacher Rating Scale (ACTeRS; Ullman, Sleator, & Sprague, 1984) measures oppositional behavior, attention problems, hyperactivity, and social problems. A less comprehensive, but similar scale, measuring only inattention and overactivity, is the Child Attention Problems (CAP) Scale developed by Edelbrock (cited by Barkley, 1990b). A relatively new instrument is the Yale Children's Inventory (YCI; Shaywitz, Schnell, Shaywitz, & Towle, 1986). The YCI was developed to screen for both learning and attentional problems as perceived by parents; it measures academic, fine motor, and language problems, in addition to attention, activity level, and impulsivity. A promising instrument for school evaluation is the Attention Deficit Disorder Evaluation Scale (ADDES; McCarney, 1989). The ADDES has both parent and teacher forms that provide ratings of the three behavioral constructs of ADD on a much larger item pool than that for the other instruments described in this section.

Multifactor Rating Scales

Several instruments used to assess children's emotional (internalizing) and behavioral (externalizing) problems broadly also measure relevant features of ADD. Because these instruments were empirically derived, however, the factors that reflect inattention, impulsivity, and hyperactivity also contain items that reflect other behaviors, such as aggression, passivity, and immaturity. For example, the original Conners (1969) Teacher Rating Scale (CTRS) measures six factors, including Hyperactivity, Conduct Problems, Emotional-Overindulgent, Anxious-Passive, Asocial, and Daydreams/Attention Problems. Five other Conners scales have been used extensively to assess ADD: the Conners Parent Rating Scale-Revised (Goyette, Conners, & Ulrich, 1978), the Abbreviated Symptom Questionnaire, (Conners, 1973; Goyette et al., 1978) parent and teacher versions, and the Iowa-Conners Scale (Loney & Milich, 1982).

Other commonly used multifactor scales are the Child Behavior Checklist (CBCL; Achenbach & Edelbrock, 1983) and the CBCL-Teacher Report Form (CBCL-TRF; Edelbrock & Achenbach, 1984). Like the CTRS, both instruments are well normed with respect to socioeconomic status and racial/ethnic composition. Whereas the Conners and CBCL instruments are commonly used in clinical research and practice, the most extensively used instruments for assessing emotional/behavioral problems in special education are the original and revised Behavior Problem Checklists (Quay & Peterson, 1987). The revised version measures six factors: Conduct Problems, Socialized Aggression, Attention Problems-Immaturity, Anxiety-Withdrawal, Psychotic Behavior, and Motor-Tension Excess. Of relevance educationally, the RBPC provides normative data on students with serious emotional disturbance, students with learning disabilities, and students without disabilities.

Rating Scales for Assessing Situational Variation

It is generally known that attention and activity level varies across different environmental contexts and at different times during the day for most individuals, including children with ADD. Accordingly, situational and temporal variability presents an assessment problem in that the symptoms of ADD are assumed to be pervasive in nature.

The literature on the assessment of ADD indicates that although attention and activity fluctuate across different settings for both children with ADD and those without disabilities, children with ADD display higher levels of inattention and overactivity than normal children and show significant deviation in more settings (Barkley, 1990a; Porrino et al., 1983; Zentall, 1985). Also, clinical evidence suggests that symptom expression may not be as evident in one-on-one assessment and instructional situations, which is why DSM-III-R emphasizes the role of teachers and parents as the best sources of diagnostic data.

Recently, two rating scales, the Home Situations Questionnaire (HSQ) and the School Situations Questionnaire (SSQ), have been developed (DuPaul & Barkley, 1992) to assess the pervasiveness of symptoms across situations/contexts. The HSQ-Revised asks parents to rate the severity of behavior problems in each of 14 situations at home (e.g., mealtimes, watching TV, playing with other children). The SSQ-revised asks teachers to rate the severity of behavior problems in each of eight school settings (e.g., seatwork, small-group activities).

Observational Measures of ADD Symptoms

Direct observational measures have been used primarily to gather confirmatory evidence to support a diagnosis of ADD based on ratings, but are also well suited for assessing situational and temporal variation in symptom expression in differing instructional activities and during different times of the school day. Three relatively standardized procedures illustrate this approach: the ADHD Behavior Coding System (ADHD-BCS; Barkley, 1990b); the Classroom Observation of Conduct and ADD (COCADD) scale (Atkins, Pelham, & Licht, 1985); and the CBCL-Direct Observation Form (DOF; Achenbach, 1986). The ADHD-BCS has been used to observe ADD symptoms in clinic playrooms and classroom settings in schools. Similarly, the COCADD contains eight behavior codes for classroom situations and another eight for playground situations. The CBCL-DOF codes classroom and group behavior in categories that correspond to the different factors measured by the CBCL (Achenbach & Edelbrock, 1983).

Structured Interviews

In general, two types of information are gathered from structured interviews that are relevant to the assessment and diagnosis of ADD. First, there are clinical interviews for parents, children, and adolescents that were developed to yield DSM diagnoses of all childhood disorders, including ADD. One example is the Diagnostic Interview for Children-Parent Form (DISC-P; Costello, Edelbrock, Kalas, Kessler, & Klaric, 1982).

The second type of interview--more useful for educational purposes--are parent interviews that provide information about current life and family circumstances; the child's developmental, social, educational, and treatment history; and information on current behavioral and educational concerns. Barkley's (1990b) ADHD Parent Interview is an example of this type of structured interview (pp. 261-277).

EDUCATIONAL ASSESSMENT OF ADD

Assessing Primary Characteristics Because the relative severity of the ADD symptoms of inattention, impulsivity, and hyperactivity can vary among children and because each may impair students' academic performance and social-emotional functioning in different ways (see Zentall, this issue), it is important that all three constructs be measured. In this regard, the literature on the educational characteristics of students with ADD and its co-occurrence with other conditions indicates that the classification of ADD should recognize at least two subtypes: ADD with and without hyperactivity (Barkley, DuPaul, & Murray, 1990; Hynd et al., 1991; Lahey & Carlson, 1991).

Assessing Co-Occurring Disabilities

Researchers have reported that ADD can co-occur with learning disabilities in at least 10-20% of cases when stringent identification criteria are applied for both conditions, although the prevalence of co-occurrence varies from 9-63% across studies (McKinney, Montague, & Hocutt, 1993). Similarly, researchers have reported consistently higher rates of co-occurrence between ADD and disruptive behavior disorders marked by aggression, oppositional-defiant behavior, and conduct problems. The evidence for the presence of co-occurring emotional problems is less consistent, but becomes significant for girls with ADD as they approach adolescence. Therefore, if a student is suspected of having ADD, it is reasonable to expect that the student may also have co-occurring LD or emotional/behavior disorder (EBD). Thus, appropriate instruments should be used to include or exclude the presence of these problems as part of a comprehensive assessment strategy.

Defining the Severity of ADD

McBurnett, Lahey, and Pfiffner (this issue) have noted that DSM diagnosis is based on the number of symptoms presented that exceed a specified threshold, and severity has been assessed rather subjectively. Instruments keyed to DSM-III (APA, 1980) and DSM-III-R (APA, 1987) have the advantage of assessing the severity of symptoms more objectively in terms of the number that exceed the required threshold, as well as overall severity based on average ratings. However, these instruments have less extensive norms compared to most multifactor, empirically derived instruments. On the other hand, empirically derived instruments do not always measure all of the three primary characteristics of ADD or measure them neatly apart from other types of problem behaviors. For example, some instruments tend to contaminate inattention with passivity or immaturity, and other instruments contaminate hyperactivity with aggression or defiant behavior.

In general, the recommended solution to this problem is to seek confirmatory evidence for the diagnosis of ADD from DSM-keyed instruments by using multifactor instruments that are relevant to ADD and that can also be used to assess co-occurring emotional and behavioral problems. Although there is no generally agreed-on statistical cut-off for severity level as assessed by standardized measures, researchers have tended to use a 2-standard-deviation cut-off, which is consistent with that commonly used in special education.

Duration of Symptoms

ADD is a pervasive disorder that appears early in childhood and persists into adult life. Our review of the preschool literature suggests that ADD with hyperactivity as the major symptom, along with aggressive or oppositional behavior, can be identified as early as 3 years, and these symptoms persist reliably in a significant number of cases well into the elementary grades (Campbell & Ewing, 1990). However, attentional problems (ADD without hyperactivity) are less visible than activity and impulse-control problems and are typically recognized by teachers during the primary period (K-3). DSM-III-R (APA, 1987) established the age of onset of ADD at 7 years and will require evidence of persistence for at least 6 months unchanged in the new edition, DSM-IV (see McBurnett, this issue). The collection of parent and teacher interview data, along with a thorough review of school records and treatment history, is important with respect to these criteria.

Also, it should be noted that the principal means for dealing with these issues in special education assessment more generally is to use prereferral intervention strategies for a specified period of time (e.g., 6 months) as part of the referral-assessment process. The application of these procedures would also provide an opportunity to evaluate general education accommodations specifically for ADD.

Situational and Temporal Variability

An important problem in assessing ADD is that evidence of pervasiveness is needed to show that inattention, impulsiveness, and hyperactivity are not specific to certain situations (e.g., displayed in school but not at home, or only in some school or home situations). We noted earlier that two assessment strategies can address this problem. First, instruments are available for collecting ratings of the severity of ADD symptoms in different school and home situations (DuPaul & Barkley. 1992). However, there is a paucity of evidence on the effects of ADD symptoms on the performance of specific instructional activities and in different instructional contexts. The second strategy, the use of observational instruments for assessing ADD symptoms and, more generally, on- and off-task behavior, is helpful in measuring academic performance, as well as in planning and monitoring the effectiveness of instructional and behavioral accommodations.

Assessing Educational Characteristics and Needs

A common finding across studies in the assessment literature on ADD is that students with ADD tend to score below normal comparison samples on IQ and achievement tests, but frequently still within the normal range (McKinney et al., 1993). Although the symptoms of ADD may impair test performance, many studies failed to control variables, such as socioeconomic status, and to account for co-occurring conditions. When children with co-occurring LD and problem behaviors were compared separately to those with ADD only in well-defined samples, evidence to suggest impaired ability and achievement was lacking (e.g., see Dykman & Ackerman, 1991). At the same time, functional outcomes for children with ADD in follow-up studies have been poor with respect to frequency of retention, suspension, and dropout rates (Barkley, Fischer, Edelbrock, & Smallish, 1990). Although these outcomes apply mainly to clinic-identified hyperactive students, there is evidence to suggest that children with ADD may become more handicapped educationally in the long term due to its association with LD and EBD and the effects of continued school failure.

In any event, the problem remains to better specify the educational characteristics of students with ADD--without the complications imposed by other co-existing conditions. In this regard, some have argued that children with ADD display difficulties in academic productivity, as assessed by work completion, on-task behavior, and accuracy of responding on academic tasks, due to the inability to regulate attention and impulse control (Fowler, Barkley, Reeve, & Zentall, 1992; Zentall, this issue). Attention and the ability to regulate behavior during task performance have long been known to affect academic performance. Inattention and poor on-task behavior combine with other variables, such as grade-level retention and impulsive cognitive styles, to predict poor academic performance cumulatively over time (McKinney, 1989; McKinney & Speece, 1986; Osborne, Schulte, & McKinney, 1991).

However, evidence of this kind is sparse for the majority of students with ADD and no other co-occurring disabilities. Accordingly, we need to go beyond the ADD literature to apply currently used methods for assessing educational needs and, in particular, instructional needs. One approach that should be considered is curriculum-based measures to identify students with ADD who may require general education accommodations as opposed to special education and related services. Such measures could also aid in planning and monitoring educational programs.

Assessing Social Adjustment and Adaptation

One of the most consistent findings in the literature on ADD is that the majority of these students have significant and persistent problems in social relationships. Also, evidence suggests that the nature of social problems is related to ADD subtypes. For example, children with ADD and hyperactivity are aggressive and rejected more often than are children without disabilities, and children with ADD but without hyperactivity are more withdrawn and unpopular, but not necessarily rejected (McKinney et al., 1993). The latter description is similar to that for students with LD (Riccio, Gonzalez, & Hynd, in press). With ADD, however, researchers have replicated these findings extensively by observation, sociometric techniques, and the opinions of parents, other adults, and peers. Accordingly, although we did not review instruments for assessing social competence in this article, it is an area of assessment that would be warranted in many cases.

SUMMARY AND CONCLUSIONS

Comprehensive assessment for educational purposes is a multistage process that gathers data and information to make decisions about the nature of children's educational problems, their need for specialized programs and services, and the efficacy of the programs and services they receive. Several brief, DSM-keyed instruments are available for screening and identifying students with ADD who are experiencing educational and behavioral problems and may be suspected of having a disability. These instruments may also indicate the need to implement prereferral interventions that feature general education accommodations that are applicable to students with ADD (see Fiore, Becker, & Nero, this issue).

However, if the screening phase proceeds to referral for a comprehensive assessment, the literature on the assessment of ADD indicates that a comprehensive assessment protocol would seek confirmatory evidence for the identification of ADD by using multiple methods (rating scales, observations, and interviews) and information from multiple sources, including parents and teachers.

In addition, evidence should be obtained on the severity of ADD symptoms in multiple situations at home and in the school. In this regard, a procedure for obtaining comparative data on representative students in the same situations is useful for assessing deviance in behavior for both rating and observational measures. Also, at the classification/diagnostic stage of assessment, it would be important to classify ADD with and without hyperactivity and assess for co-occurring LD and emotional or behavior problems.

Several issues concerning educational assessment are unresolved by the current research literature on ADD. Some of these issues reflect the adequacy of the knowledge base, while others are procedural in nature. First, although we are confident that consensus can be achieved on what constitutes a comprehensive assessment of ADD for educational purposes, an assessment protocol such as that envisioned here and recommended by many (e.g., Atkins & Pelham, 1991; Fowler et al., 1992; Guevremont, DuPaul, & Barkley, 1990) has not been evaluated in practice and is rarely used to identify research samples. Therefore, we have little evidence that would tell us about the prevalence and characteristics of children with ADD who would be so identified under stringent standards. For that matter, we have little evidence about the number and characteristics of those with ADD who currently receive special education and related services, or about the nature and type of services they receive.

Second, we were disappointed by the small number of studies in the literature that assessed educationally relevant variables that would inform us more directly about how inattention, impulsivity, and overactivity impair learning on specific instructional tasks and in different educational settings. Although progress has been made in this area (Zentall, this issue), it is evident that we must apply what we know from the literature in general and special education more broadly; and we must conduct additional research to validate promising approaches to fill the gaps in both basic and applied research on ADD.

Third, existing literature on ADD is not adequate as a guide to what assessment data are necessary and sufficient to qualify a child with ADD for general education accommodations under Section 504, as opposed to special education and related services under IDEA. Similarly, the literature is inadequate as a guide to developing consensus on the appropriate roles of professionals in the assessment/identification process.

In sum, we believe that we need further research on some aspects of assessment, as well as more professional dialogue on substantive procedural issues.

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ABOUT THE AUTHORS

JAMES D. MCKINNEY (CEC #100), Professor of Education, University of Miami, Coral Gables, and Director. Miami Center for Research on Attention Deficit Disorder. MARJORIE MONTAGUE (CEC #114), Associate Professor of Education, University of Miami, Coral Gables, and Co-Director, Miami Center for Research on Attention Deficit Disorder. ANNE M. HOCUTT (CEC #121). Research Investigator, Miami Center for Research on Attention Deficit Disorder, and Adjunct Assistant Professor, Department of Educational and Psychological Studies, University of Miami, Coral Gables, Florida.

Preparation of this article was supported in part by the Department of Education, Office of Special Education Programs, Grant #H023S10013. The opinions of the authors do not necessarily reflect the positions or policy of the funding agency.
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Author:McKinney, James D.; Montague, Marjorie; Hocutt, Anne M.
Publication:Exceptional Children
Date:Oct 1, 1993
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